Patient Partners for Equity Organization Profile Form

Name of Organization*

Website Address*

Mailing Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Name of Primary Organizational contact*

First

Last

Email of Primary Organizational contact*

Phone number of Primary Organizational contact*

Will this contact be the POC for the Patient Partner for Equity Program?*

Yes
No

Name of Secondary Organizational contact

First

Last

Email of Secondary Organizational contact

Phone number of Secondary Organizational contact

Will this contact be the POC for the Patient Partner for Equity Program?

Yes
No

Please provide the Organization’s Mission Statement*

Please upload the logo for use on the PAF websites

(500px maximum, .jpg format preferred .png also acceptable)

What is your geographic focus?*

Please Specify Below

Geographic Details

Is your organization designated as a nonprofit organization?*

Please provide details below

Please provide details if you are not a nonprofit organization*

Does your organization focus mainly on a particular disease or condition?*

Please select one that best describes your organization and provide details below.

We focus on multiple diseases or conditions, including cancer
We focus on one or more diseases or conditions but not cancer
We focus on all types of cancers
We focus on a few or certain types of cancers, diseases or conditions
We focus on one cancer, disease or condition
We do not focus on any specific diseases or conditions

Please provide details about your organization's disease area(s) of focus.*

What types of diseases does your organization focus on?*

Please select all that apply. You must select at least one

Disease or Condition Area of Focus Details*

Which of the following topics do you consider a major focus for your organization as it relates to health, cancer or other chronic and serious diseases or conditions?*

Please select all that apply.

Other (please specify}

Does your organization provide direct support to patients, families and/or caregivers through a dedicated patient hotline/call center or peer to peer programs?*

Yes
No

Does your organization have a formalized health equity and inclusion (HEI) or diversity, inclusion and equity (DEI) program?*

Yes
No, but we have a HEI or DEI priority or imperative as an organization
No

Does your organization focus on one particular group or population?

Please provide any details on the population you focus on most.

Which of the following describe reasons why you might partner with an organization?*

Please select all that apply.

Which of the following are important components of your organization's programs or initiatives?*

Please select all that apply.

Overall, about how many people did your organization reach in the last year?

By completing this organizational profile, you are confirming the following:

Your organization’s desire to partner with PAF as a Patient Partner for Equity
PAF has permission to utilize your logo and mission statement on our websites, www.patientadvocate.org and www.copays.org , on the Patient Partner for Equity pages.
PAF has permission to add the primary, secondary and program contacts provided in this profile form to the Patient Partner for Equity listserv for the purposes of receiving PAF and NPAF communications relative to the Patient Partner for Equity and other general organizational communications. Emails will be sent from PAF's email management system, MailChimp.

I understand and agree to these conditions.*

Yes
No